OBJECTIVE: The objective was to evaluate whether severity of cardiac illness, cognitive functioning, and functional health of older adults with heart failure (HF) and psychosocial factors related to caregiving are predictive of hospital readmissions for those with HF.
DESIGN: A prospective, descriptive, predictive design was used.
SETTING: The study took place in 2 community hospitals in northeastern Ohio.
SAMPLE: Originally 156 patient-caregiver dyads were interviewed within 7 to 10 days of hospital discharge, but only 128 dyads completed the study. Subjects had HF and their mean age was 77.3 years. Their caregivers were mostly women with a mean age of 64.8 years.
RESULTS: Fourty-four percent of the patients were readmitted to the hospital within 3 months. Among patients, severity of illness was moderate, blood pressure was within normal limits, functional and cognitive status were high. For patients, the interaction of severity of cardiac illness and functional status predicted risk of hospital readmission. Among caregivers, depressive symptoms and perceived stress were low; informal social support and caregiving appraisal were high. The interaction of caregiver stress and depression were significant predictors of risk of hospital readmission.
CONCLUSION: Nurses should consistently assess changes in patients' cardiac symptoms in addition to their ability to provide self-care. Since patients with HF are at high risk for readmission, further study is needed to determine whether interventions designed to increase spousal support would decrease hospital readmissions.
STUDY OBJECTIVE: To determine the relationship between adherence to diuretic therapy and health care utilization.
DESIGN: Prospective, observational study.
SETTING: University-affiliated medical center.
PATIENTS: Forty-two patients with heart failure.
INTERVENTION: Electronic monitoring of adherence to diuretic therapy (percentage of diuretic prescription container openings) and to scheduling (percentage of container openings within a specific time).
MEASUREMENTS AND MAIN RESULTS: All patients were prescribed a diuretic, most commonly furosemide (88%). Patients varied widely in adherence to therapy (mu = 72% +/- 30%) and to scheduling (mu = 43% +/- 30%). Education was a predictor of drug-taking adherence (p=0.0062) but not of scheduling adherence. Log-linear models revealed that poor scheduling adherence was associated with increased cardiovascular-related hospitalizations (chi2 11.63, p=0.0006) and predicted more heart failure-related hospitalizations (chi2 4.04, p=0.0444). In contrast, neither measure was significantly associated with cardiovascular- or heart failure-related emergency department visits. We found a moderate correlation between scheduling adherence and taking adherence (r = 0.6513).
CONCLUSION: Patients taking a greater proportion of diuretic agents on schedule may decrease the risk of cardiovascular- and heart failure-related hospitalizations. If these findings are confirmed by a larger study, interventions to improve adherence and patient health outcomes should consider the timing of doses as well as the number of daily doses of a diuretic.
INTRODUCTION: This study was conducted to develop a detailed profile of patients who come to the emergency department for heart failure treatment.
METHODS: Patient interviews were supplemented by medical record reviews in a convenience sample of 57 participants. A structured interview guide included data concerning patient characteristics and ED treatment.
RESULTS: Participants used a variety of self-care strategies before coming to the emergency department. Many of the patients studied (25%) reported barriers to medication adherence, such as memory problems and lack of knowledge regarding self-administration. The most frequently reported symptoms were breathing difficulties (88%), chest discomfort (35%), and fatigue (16%). Seventy-four percent of the participants were classified as specific activity scale class III or IV, indicating moderate to severe functional limitation. Mean quality of life at the time of interview was 5.1 (on a 1 to 10 scale). Length of stay was < or = 2 days for 33%.
DISCUSSION: A number of the findings of this study have implications for ED nurses. For example, almost one third of the patients studied had not received directions for a low-sodium diet during hospitalization, when fluid volume overload with sodium retention was the most common cause of hospitalization in a study of patients with decompensated heart failure. Hospital lengths of stay of no more than 2 days suggest that early detection and treatment of acute heart failure may reduce the need for ED visits for some patients. Patients need education and support with self-help strategies and need to better understand the administration of their medication.
Outpatient heart failure centers using a multidisciplinary approach to management of heart failure are recognized as essential to decreasing costs of treating heart failure. These centers do not typically employ registered dietitians. With hospital foundation funding, our objective was to develop the role of the dietitian and to evaluate the impact of nutrition intervention in a multidisciplinary heart failure program. Based on a needs assessment, the dietitian developed and tested a medical nutrition therapy protocol, education materials, and special education projects. Unannounced 24-hour recalls at 3 points in time were used to determine changes in sodium and fluid intakes. An outcome tracking system was implemented. Intake data were analyzed for patients who were in the program 9 or more months (n = 79). Patients' sodium and fluid intakes at 2 to 3 months and 6 to 9 months were compared with their baseline intakes using paired t test. The sodium decrease of 0.5 g at 2 to 3 months and 6 to 9 months and the fluid decrease of 15 oz at 2 to 3 months and 12 oz at 6 to 9 months were all highly significant (P < .001). Patients active in year 3 (n = 82) completed the Minnesota Quality of Life Questionnaire. Compared with baseline, quality of life scores improved by 6.7 points (P < .003) at 3 months and by 5.9 points (P < .04) at 6 months. Of 83 patients hospitalized over 3 years, 6 hospitalizations were the result of an excessive sodium intake. At the completion of the project, the center provided funding for the dietitian to become a permanent team member. These positive findings indicate dietitians should seek involvement in heart failure centers.
This study examined adherence to angiotensin-converting enzyme inhibitor therapy among 171 heart failure clinic patients. Adherence was monitored over a 3-month period with an electronic event monitor housed in a medication bottle cap, which recorded the date and time the cap was opened and closed. The average percentage of days that the prescribed number of doses (regimen adherence) was taken over the observation period was 84%. Seventy-one percent of patients showed 85%-100% adherence with their daily regimen; 19% exhibited less than 70% adherence. The overall high rates of adherence to angiotensin-converting enzyme inhibitor therapy observed among heart failure clinic patients is consistent with research that shows improved outcomes for patients managed in heart failure clinics. Electronic medication monitoring can be useful in identifying a substantial fraction of patients who are poorly adherent so that interventions to improve adherence can be targeted toward them. Additional research is needed to develop and test adherence-enhancing interventions.
Due to the ageing of the population and increased survival of patients with acute coronary artery disease, an ‘epidemic’ of heart failure is emerging, illustrated by increasing rates of hospitalisations for heart failure and resulting in a considerable increase in the cost of care for these patients. In the past decades new insights in the pathophysiology of heart failure and evidence of the benefits of several categories of drugs have made treatment of heart failure more rewarding. Treatment, however, has also become more complex. Patients with heart failure are in general over 70 years old and have a history of ischaemic heart disease and multiple comorbidities. Treatment of both heart failure and these comorbidities leads to the use of a broad range of very powerful medicines. The inappropriate use of these medicines can have a major impact on outcomes of pharmacotherapy. This thesis gives an overview of changes in the drug treatment of heart failure between 1990 and 1998 and addresses a range of drug related problems in patients with chronic heart disease. Topics addressed are patient non-compliance, early discontinuation of drugs, underutilisation of drugs with proven benefits, adverse drug reactions and interactions. Several suggestions to improve management and pharmacotherapy in heart failure, both for prescribers and pharmacists, are provided.
Congestive Heart Failure is a costly debilitating medical condition that affects millions of elderly people. This Clinical Practice Improvement study was under taken to determine how variation in patient characteristics and clinical processes impact patient outcomes including length of stay, total charges, and increased severity of illness during hospitalization. The AHCPR Guideline for Heart Failure was used to evaluate clinical care. Data on patient characteristics including severity of illness and process of care were analyzed to determine which variables had the greatest impact on outcomes of care. Results showed that patient characteristics including comorbidities, severity of illness, and noncompliance with diet were significantly related to longer lengths of stay, higher charges, and/or increased severity (all covariates, p < .05). In addition, process of care variables including medication use and patient education significantly (p < .05) impacted outcomes of care. Findings have implications for the development of practice guidelines designed to improve patient outcomes associated with CHF hospitalizations.
BACKGROUND: One way to prevent frequent hospitalizations and promote positive health outcomes among patients with heart failure (HF) is to ensure that the amount and quality of self-care used is appropriate to the patient's situation.
OBJECTIVES: The following are the purposes of this study: (a) examine the frequency of performance of self-care behaviors, (b) describe personal and environmental factors (basic conditioning factors [BCFs]) that affect self-care behaviors, and (c) describe the relationship between the level of knowledge patients have to empower their performance of self-care and the actual performance of self-care behaviors.
METHODS: This descriptive correlational study was guided by Orem's theory of self-care. One hundred ten participants, predominantly African Americans, who were outpatients or inpatients ready for hospital discharge, 18 years or older, and diagnosed with HF that was confirmed by an ejection fraction of 40% or less were conveniently selected from 1 of 2 sites. Data were collected with 2 investigator-developed instruments: the Revised Heart Failure Self-Care Behavior Scale and the Heart Failure Knowledge Test. Descriptive statistics, correlational analyses, and t tests for independent samples were used to analyze the data.
RESULTS: Three of the top 5 most frequently performed self-care behaviors were related to taking prescribed medications, and the 5 least frequently performed self-care behaviors were concerned with symptom monitoring or management. There were no significant relationships between the total self-care behavior score and any of the BCFs; however, a number of significant relationships between BCFs and individual self-care behaviors were observed. There was a significant relationship between the mean total knowledge score and the total mean self-care score (r = 0.21, P =.026).
CONCLUSION: Detailed information about the influence of BCFs on the performance of specific HF self-care behaviors can help nurses tailor interventions to the patient's situation.
OBJECTIVES: We sought to determine whether a multidisciplinary outpatient management program decreases chronic heart failure (CHF) hospital readmissions and mortality over a six-month period. BACKGROUND: Hospital admission for CHF is an important problem amenable to improved outpatient management. METHODS: Two hundred patients hospitalized with CHF at increased risk of hospital readmission were randomized to a multidisciplinary program or usual care. A study cardiologist and a CHF nurse evaluated each patient and made recommendations to the patient's primary physician before randomization. The intervention team consisted of a cardiologist, a CHF nurse, a telephone nurse coordinator and the patient's primary physician. Contact with the patient was on a prespecified schedule. The CHF nurse followed an algorithm to adjust medications. Patients in the nonintervention group were followed as usual. The primary outcome was the composite of the number of CHF hospital admissions and deaths over six months, compared by using a log transformation t test by intention-to-treat analysis. RESULTS: The median age of the study patients was 63.5 years, and 39.5% were women. There were 43 CHF hospital admissions and 7 deaths in the intervention group, as compared with 59 CHF hospital admissions and 13 deaths in the nonintervention group (p = 0.09). The quality-of-life score, percentage of patients on target vasodilator therapy and percentage of patients compliant with diet recommendations were significantly better in the intervention group. Cost per patient, in 1998 U.S. dollars, was similar in both groups. CONCLUSIONS: This study demonstrates that a six-month, multidisciplinary approach to CHF management can improve important clinical outcomes at a similar cost in recently hospitalized high-risk patients with CHF.
BACKGROUND: Treatment-seeking delays for heart failure (HF) symptoms are significantly high. However, earlier studies did not closely examine race as a characteristic that could potentially influence delay times. The purpose of this study was (1) to describe racial differences in treatment-seeking delays for HF symptoms and (2) to identify racial differences in hospital readmission rates, functional status, and total length of stay.
METHODS AND RESULTS: A retrospective chart review of all patients admitted with HF at a Veterans Administration facility was conducted. The study sample consisted of 753 patients: 456 Caucasians (60.6%), 220 African Americans (29.2%), 41 Asians (5.4%), and 36 Hispanics (4.8%). The average prehospital delay time was 2.9 +/- 0.7 days. Mean delay times were significantly longer for African Americans than for Caucasians, Asians, and Hispanics (P =.019). African Americans also had significantly higher readmission rates (P =.001) and lower functional status (higher New York Heart Association functional class) (P =.034). There were no significant racial differences in total length of stay for HF admissions.
CONCLUSION: The current study supports that racial differences exist in treatment-seeking behaviors for HF symptoms, hospital readmission rates, and functional status. A better understanding of treatment-seeking behaviors of HF patients with different racial characteristics may be key to early recognition and prevention of complications in this high-risk population; it may be beneficial in identifying patients at risk for treatment delays and potentially poorer outcomes.
The objective was to evaluate whether severity of cardiac illness, cognitive functioning, and functional health of older adults with heart failure (HF) and psychosocial factors related to caregiving are predictive of hospital readmissions for those with HF.
DESIGN:
A prospective, descriptive, predictive design was used.
SETTING:
The study took place in 2 community hospitals in northeastern Ohio.
SAMPLE:
Originally 156 patient-caregiver dyads were interviewed within 7 to 10 days of hospital discharge, but only 128 dyads completed the study. Subjects had HF and their mean age was 77.3 years. Their caregivers were mostly women with a mean age of 64.8 years.
RESULTS:
Fourty-four percent of the patients were readmitted to the hospital within 3 months. Among patients, severity of illness was moderate, blood pressure was within normal limits, functional and cognitive status were high. For patients, the interaction of severity of cardiac illness and functional status predicted risk of hospital readmission. Among caregivers, depressive symptoms and perceived stress were low; informal social support and caregiving appraisal were high. The interaction of caregiver stress and depression were significant predictors of risk of hospital readmission.
CONCLUSION:
Nurses should consistently assess changes in patients' cardiac symptoms in addition to their ability to provide self-care. Since patients with HF are at high risk for readmission, further study is needed to determine whether interventions designed to increase spousal support would decrease hospital readmissions.
